P101672 Wells. .
DAVIE COUNTY HEALTH DEPARTMENT SEPTIC TANK PERF±IT Date z o
Jwner/Occupant O C _ To:
Address Address,
104 n n L�----- Address �r
Cal. t c3 Manufacturer' Name ,T bo Address
No. of lines `I_ Width _in. Total length ft. No. sq. £t. �c3a
Type of filter material Tot%l tons used
Minimum REquirements: House Trifler Tank cap. 800- Sq. ft. line 400
Two-bedroom house 800 600
Three-bedroom house 900 900
No one shall install a septic tank in Davie County without a permit from the Health Offic
or his agent.
Date of Final Approval
Signed:
Sanitarian
I hereby certify that the above septic tank has been installed according to specification
Signed:
Septic Tank Contractor
Note: Make sketch of disposal system on back of sheet and mail to Davie County Health
Center, Box 57, Mocksville, North Carolina 27028.